Psych Emergencies Flashcards
pt factors associated with violence
signs of impending violence
management of the aggressive pt
pt factors associated with violence
- male
- history of violence
- drug or alcohol abuse
signs of impending violence
- provocative behavior
- angry demeanor
- loud, aggressive speech
- tense posturing
- frequently changing body position
- aggressive acts
management of the aggressive pt
- expedite evaluation
- verbal techniques: address violence directly, set limits, be honest, calm and soothing tone of voice
- protect yourself
- physical restraints
Physical restraints
- indications
- tips for restraints
- monitor closely for (3)
Indications
- imminent harm to others or self
- significant disruption of important treatment or damage to environment
- continuation of effective, ongoing behavior treatment plan
Tips
- should be at least a 5 person team
- provider not included to maintain the relationship
- if pt is female, at least on member needs to be female
- DOCUMENTATION why physical restraints required
Monitor closely
- position changes
- lrespiration
- avoid aspiration
Chemical restraints
- classes of meds used (3)
- examples of each class
- which is the preferred drug when sedating pts that are agitated from an unknown cause?
Classes
- benzos (lorazepam, midazolam)
- first generation antipsychotics (haldol, droperidol)
- second generation antipsychotics (risperidone. geodon, zyprexa)
Preferred
-benzos when agitated from an unknown cause
First generation antipsychotics
-when to avoid
What drugs are used for:
- severely violent pt requiring immediate sedation
- pts with agitation from drug intoxication
- pts with undifferentiated agitation
- agitated pts with a known psych disorder
Avoid
- cases of alcohol withdrawal
- benzo withdrawal
- other withdrawal sx
- anticholinergic toxicity
- pts with sz
- pregnant and lactating
What drugs are used for:
- severely violent pt requiring immediate sedation= first generation AP and/or benzo
- pts with agitation from drug intoxication= benzo
- pts with undifferentiated agitation= benzo preferred, first gen AP can be used
- agitated pts with a known psych disorder= first or second generation AP
T/F, when a provider restrains a pt, the provider becomes responsible for the well being of the patient.
Post-restraint medical evaluation
-what is included
True
Post restrain medical evaluation
- vitals and pulse ox
- mental status exam
- neuro exam
- rapid blood glucose determination
- rule out any medical condition
AIDS Encephalopathy
- presentation
- MC etiologies
- dx
- tx
Presentation
- change in mental status
- abnormal neuro exam
MC etiologies
- toxoplasmosis encephalitis
- primary CNS lymphoma
- progressive multifocal leukoencephalopathy
- HIV encephalopathy
- CMV encephalitis
Dx
-CT/MRI
Tx
-follow the algorithm, figure out the cause, and treat it…
Psychosis:
- definition
- what are some disorders that have psychosis?
Definition:
disturbance in the perception of reality, evidenced by hallucinations, delusions, or thought disorganization. Psychotic states are periods of high risk for agitation, aggression, impulsivity and other forms of behavioral dysfunction
Disorders:
- schizophrenia
- bipolar mania
- Major depression with psychotic features
- schizoaffective disorder
- alzheimers dz
- delirium
- delusional disorder
- psychosis 2ndry to a medical condition
Cocaine
- adverse effects
- sx
- sx of withdrawal
- tx of withdrawal
Adverse effects:
- anxiety/irritability
- panic attacks
- suspiciousness/paranoia
- grandiosity/impaired judgement
- psychotic sx – delusions/hallucinations
Sx:
- tachycardia
- tachypnea
- HTN
- hyperthermic
- diaphoretic
- dilated pupils
- hyperreflexic
- tremor
Withdrawal sx:
- depression, anxiety, fear, difficulty concentrating, cravings, increased sleep, increased appetite
- arthralgias, tremor, chills
Tx of withdrawal:
- mainly supportive
- hospitalize for psychological sx
Meth:
- sx
- dx
- complications
- labs you might need
- tx
Sx:
- tachycardia
- tachypnea
- HTN
- hyperthermic
- diaphoretic
- dilated pupils
- hyperreflexic
- tremor
- paranoia, psychosis, and delusions
- homicidality and suicidality
- mood distrubances, anxiety, hallucinations
Dx:
- sympathomimetic toxidrome
- differentiate it from cocaine and PCP..requires toxicology screen.
Complications:
-hypovolemia, metabolic acidosis, hyperthermia, and rhabdo*
Labs:
- serum lytes
- serum lactate
- creatinine kinase
- aminotransferases
- clotting times
- renal function
- ABG
Tx:
- agitation = benzos or 2nd generation antipsychotics
- keep them cool (control hyperthermia)
- HTN = nitroprusside or phentolamine (AVOID beta blockers)
Neuroleptic Malignant Syndrome:
- what is this?
- sx
- onset
- dx
What: life threatening neurologic emergency associated with the use of neuroleptic agents. Most are seen with 1st generation ant-psychotics
Sx:
- mental status change
- muscular rigidity
- hyperthermia
- autonomic instability (labile BP, tachycardia, bradycardia, difficulty urinating)
onset: within the first 2weeks of therapy
Dx: tests to r/o other conditions
- MRI or CT
- LP
- CBC
- Chem panel
- EEG
- Tox scrren
- Creatinine Kinase elevation (4x upper limit of normal, rhabdo)**
Tx:
- stop the causitive agent
- if d/t dopamine withdrawal restart dopamine
- aimed at preventing:
- -dehydration
- -electrolyte imbalance
- -Acute renal failure associated w/ rhabdo
- -Cardiac arrhythmias
- -MI
- -cardomyopathy
- -Resp failure
- -DVT
- -DIC
- -Seizures
- -Hepatic Failure
- -Sepsis
Alcohol Withdrawal:
- signs/sx
- after how many hours do withdrawal seizure occur?
- tx of withdrawal seizures?
signs/sx:
- withdrawal seizure s
- alcoholic hallucinosis
- delirium tremens
- ethanol poisoning
12-48hrs after last drink is when withdrawal seizures occur.
Treat withdrawal seizures with benzodiazepines and if necessary phenobarbital
Alcoholic Hallucinations:
- develop within how many hours?
- what types?
- tx
Develop within 12-24hrs after last drink and resolve within 24-48hrs
Usually visual but auditory and tactile hallucinations can occur.
Tx:
- supportive
- use benzo if they are really agitated
Delirium Tremens:
- after how many hours does this occur after last drink?
- signs and sx
- tx
occurs 48-95hrs after last drink and can last 1-5days
Signs and sx:
- hallucinations
- disorientation
- agitation
- tachycardia, HTN, fever
- diaphoresis
Tx:
- Supportive
- benzos if not working can add phenobarbital
- IV fluids
- Nutritional supplementation (K_ Magnesium
- Thiamine**
- *DO NOT give antipsychotics b/c they lower the seizure threshold.
Panic Attacks:
- definition
- dx
Definition: sudden onset of intense fear and development of specific somatic, cognitive, and affective sx.
Dx: clinical
- must r/o other potential causes such as:
- -angina, arrhythmias COPD PE, hyperthryroidism, pheochromocytoma, etc.
Deprssive states:
- sx
- what must you always ask about?
Sx:
- anhedonia
- lethargy
- early morning awakenings
- change in appetitie
- decreased libido
- poor concentration
- poor hygiene
- suicidal ideations
you must always ask about suicidal, homicidal, and manic states!!!
Depressive States:
-how do we evaluate suicide risk? what are some good questions to ask?
Evaluate suicide risk through Hx.
Make sure to ask if they have a plan, means and lethality to complete the act.
Presence of psychotic sx or severe anxiety
Presence of alcohol or other substance use
Hx and seriousness of previous attempts
FHX of suicide
degreee of hopelessness and impulsivity
Schizophrenia:
- what are some suggested interview questions?
- dx
- tx
Questions:
- hearing voices?
- seeing or hearing thins others dont?
- can you feel things touching you or crawling on your skin when thers nothing there?
Delusions:
- are you concerned people are following you, spying on you, or trying to hurt you?
- do you have special powers or abilities
Ideas of references:
- are people reading your thoughts?
- are you reading their thoughts?
- are you recieving special messages to you or about you from the TV, radio, or recorded music?
Dx: clinical
Tx:
-injectable antipsychotics
Catatonia:
- signs and sx
- causes
- tx
Signs and sx:
- immobility
- stupor
- mutism or incomprehensible phrases
- muscular rigidity w/ waxy flexibility
- posturing
- staring
- is a behavioral syndrome in which they have the inability to move normally despite the physical capacity to do so.
Causes:
- major depression
- manic episodes
- encephalitis
- antipsychotics, benzo withdrawals
- hepatic encephalopathy
- SLE
- WIlsons or Lymes dz
Tx:
- treat the underlying cause
- supportive
- Lorazepam (ativan)
- ECT (mortality may increase with not begun within 5days of sx onset)
Manic State:
- signs and sx
- management
Signs and sx:
- high risk activities
- spending a lot of money
- traveling across the country
- gambling
- no sleep
- risky sexual activity
- grandiosity
Conversion disorder:
- what is this?
- what can you do for this patient?
What: neurologic sx that are inconsistent with a neurologic dz, but causes distress and/or impairment
There is not much to do for them, refer to psych.
Somatization:
- what is this?
- sx
- why do people do this?
- tx
What: syndrome of nonspecific physical sx that are distressing. may not be fully explain by a known medical condition after appropriate investigation. May be conscious or unconscious.
Sx: anxiety, depression, interpersonal conflict, can be almost any sx
May be influenced by a desire for the sick role or for personal gain**
Tx: psych referral
Serotonin Syndrome: -causes -sx -dx 38C -
Cause; being on a serotonergic agent
Sx:
- mental status changes
- autonomic hyperactivity
- neuromusculr abnormalities = hyperreflexia**
Dx:
- Hunters Criteria:
- -must be taking a serotonergic agent and meet ONE of the following:
- -spontaneous clonus
- -inducible clonus PLUS agitation or diaphoresis
- -ocular clonus PLUS agitation or diaphoresis
- tremor plus hyperreflexia
- hypertonia PLUS temp above 38C PLUS ocular or inducible clonus.
Serotonin Syndrome:
- tx
- what are some common meds causing this syndrome?
Tx:
- D/c serotonergic agent
- supportive: O2, IV, etc.
- sedation w/ benzods
- control hyperthermia
- serotonin antagonsits:
- -cyproheptadine (Periactin)
- -antihistamine w/ nonspecific serotonergic antagonist properties
Meds:
- codeine, fentanyl, meperidine, tramadol
- abx=linezolid
- Antidepressants = SSRI, SNRI, TCA, MAOIs
- dopamine agonisits = amantidine, bromocriptine, levodopa
- Triptans = sumatriptain, rizatriptan, eletriptain
- amphetamines, cocain, LSD
Involuntary Psychiatric Admissions
- what are the requirements for this
- what are the types of involuntary hopsitilization?
Requirements:
- presene of a mental illness
- dangerous behavior towards self or others
- inability to adequately care for self.
Types:
- emergency detention
- observational commitment
- extended commitment
Emergency use of psychotropic meds
-when are these used?
T/F, if a pt divulges to you that they are going to harm a specific person it is your duty to warn that person of the pts intentions?
When: for pts who are considered imminently dangerous to others, either physically or psychologically and refused to take the medications freely,
True. this is the duty to warn.
Benzo use in the er?
Benzo:
- SE?
- signs of overdose?
Benzos in the ER:
- tx of alcoholic or sedative withdrawal
- acute agitation
- acute mannia or agitated psychosis
- controlling drug-induced hyperexcitable states (meth, PCP)
SE Benzo:
- sedation
- lethargy
- resp depression**
- impaired psychomotor skills and judgement
- congitive dysfunction
- delirium
- ataxia
- Death
signs of overdose:
- slurred speech
- incoordination
- unsteady gait
- impaired attention or memory.
Antipsychotic meds:
- what are the neuroleptics?
- SE of 1st gen
- indications of 1st gen?
- what are the 2nd generation antipsychotics?
- 2nd gen antipsychotic are approved to treat what disorders?
- SE of 2nd gen antipsychotics
Neuroleptics = 1st generation antipsychotics
-Haloperidol
SE 1st gen:
- galactorrhea and amenorrhea from increased prolactin
- NMS
- prolonged QT
- sudden death
indicatinos of 1st gen:
-sedation and control of psychosis in emergent situations
2nd gen antipsychotics:
- risperidone
- zyprexia
- seroquel
- geodon
2nd gens approved to tx:
- schizophrenia
- acute bipolar
- acute agitation
SE of 2nd gen:
- sedation
- hypotension
- NMS
- sudden death
